SMS, Governance and Accountability

1. SMS, Governance and Accountability Kathy Fox, Board Member Transportation Safety Board of Canada Signal Charlie Human Factors Seminar Pensacola, Florida13-14 September 2012

2. Outline • Evolution of accident investigation • Drift into failure • Safety Management Systems (SMS) • Investigating for organizational factors • Inadequate risk analysis • Employee adaptations • Goal conflicts • Weak signals • The role of governance / regulatory oversight

3. Background • “What” happened vs. “why” it happened • Evolution of accident investigation: • aircraft design • cockpit design • physiological factors • psychological influences on decision-makingand risk-taking • performance of the flight crew, not just the pilot (CRM, TEM)

4. Reason’s Model (“Swiss cheese”)

5. Service Safety Balancing Competing Priorities

6. Limits of Acceptable Performance

7. Organizational Drift “Drift is generated by normal processes of reconciling differential pressures on an organization (efficiency, capacity utilization, safety) against a background of uncertain technology and imperfect knowledge.” -Dekker (2005)

8. MK Airlines (October 2004)

9. Impact of Management By their nature, management decisions tend to have a wider sphere of influence on how the organization operates, and a longer-term effect, than the individual actions of operators. Decision-makers need to develop “mindfulness” to avoid “blind spots.” -Weick & Sutcliffe (2007)

10. A “Mindful Infrastructure” Would … Track small failures Resist oversimplification Remain sensitive to operations Maintain capabilities for resilience Take advantage of shifting locations of expertise Listen for, and heed, weak signals

11. Safety Management Systems (SMS) SMS integrates safety into all daily activities. “It is a systematic, explicit, and comprehensive process for managing safety risks … it becomes part of that organization’s culture, and [part] of the way people go about their work.” -Reason (2001)

12. SMS Requires the Following:

13. SMS Requirements in Canada • Airline operators • Maintenance organizations • Certified airport authorities • Privatized providers of air navigation services • Coming soon: commuter airlines, air taxis, flight-training units

14. Investigating for Organizational Factors • Inadequate risk analysis • Employee adaptations • Goal conflicts • Missed “weak signals” • COMPLEX INTERACTION = NO SINGLE FACTOR AS SOLE CAUSE

15. Inadequate Risk Analysis TSB Investigation Report A07A0134

16. Aircraft Attitude at Threshold

17. Inadequate Risk Analysis (cont’d) TSB Investigation Report A07Q0213

18. Employee Adaptations • Faced with time pressures or multiple goals, workers and management may be tempted to create “locally efficient practices.” • Why? To get the job done! • Past successes are taken as a guarantee of future safety.

19. Employee Adaptations (cont’d) TSB Investigation Report A09W0037

20. Goal Conflicts YVR seaplane dock, 16 November 2008 (A08P0353).

21. Weak Signals Collision with terrain: Sandy Bay, SK (A07C0001)

22. Weak Signals (cont’d) “We didn’t see [these recent accidents] coming, and we should have … the data were trying to tell us something.” -William Voss, President and CEO of Flight Safety Foundation

23. Pilot Error or Management Error? Drift, goal conflicts and adaptations are natural No one sets out to have an accident; they just want to get the work done The decision to value production over safety is implicit

24. Pilot or Management Error? (cont’d) With each success, people underestimate the amount of risk involved If investing in safety improved quarterly returns, the company would do it There is a complex relationship between culture and process

25. The Role of Governance / Oversight Q.) Who holds decision-makers to account? A.) Board of Directors / owner Shareholders / financial backers Customers Insurance companies Regulators All of the above

26. Governance / Oversight (cont’d) TSB Investigation Report A10Q0098

27. Governance / Oversight (cont’d) “The gap between what is legal and what is safe already is large, and it will get bigger. … Is this regulatory approach sustainable? Is it fair to airlines that do everything right? Is it fair to an unknowing public?” -William Voss, Flight Safety Foundation

28. Conclusions • Old views of safety are changing • No one can predict the future perfectly • “Mindful infrastructure” Effective SMS depends on “culture” and “process” • Accountability is key • Regulatory oversight • Success takes time

29. Questions?